DealBook: How Pursuit of Billionaire Hit One Dead End

When Jonathan Hollander left his high-flying job at SAC Capital Advisors in late 2008, he departed one of Wall Street’s premier hedge funds.

Weeks later, when two Federal Bureau of Investigation agents confronted him outside the Equinox gym in Greenwich Village, Mr. Hollander realized that investigators viewed his former employer as something else — a corrupt organization rife with insider trading.

The agents took Mr. Hollander into a nearby cafe and questioned him about his trading in the stock of a supermarket chain. They showed him a sheet of paper with headshots of several of his former colleagues. At the center was a photograph of Steven A. Cohen, the billionaire owner of SAC, according to two lawyers briefed on the meeting who requested anonymity because they were not authorized to discuss it publicly. The agents compared Mr. Cohen to a Mafia boss who sat atop a criminal enterprise, the lawyers said.

In the end, no criminal case was filed against Mr. Hollander. And neither Mr. Cohen nor SAC has been accused of any wrongdoing. Mr. Cohen has told employees and clients that he and SAC have at all times acted appropriately.

An examination of Mr. Hollander’s case, based on a review of court documents and interviews with people involved in the investigation, provides a lens into the government’s aggressive crackdown on insider trading and fierce pursuit of Mr. Cohen over the last decade. Investigators saw Mr. Hollander as a suspect, and he also piqued their interest as someone who could open a window into SAC and Mr. Cohen.

Yet the investigation of Mr. Hollander, 37, also highlights the challenges of using lower-level employees to build a case against their boss.

Hedge Fund Inquiry

The authorities have moved on from Mr. Hollander, who is working as an entrepreneur. Today, they are focused on another former junior SAC employee, Mathew Martoma, who is fighting a recent indictment and refuses to cooperate with the government. Mr. Martoma’s case has increased the pressure on SAC and Mr. Cohen, who was involved in the trades at the center of the charges against Mr. Martoma.

While Mr. Hollander provided prosecutors with no such direct link to Mr. Cohen, some authorities thought he possessed a rich vein of information about his former employer. Others dismissed him as a junior analyst who offered uncorroborated tips at best, lawyers close to the case recalled.

With authorities at odds over his importance and the strength of the evidence against him, Mr. Hollander’s criminal case fizzled.

The Securities and Exchange Commission settled a lawsuit with Mr. Hollander related to improper trading in his personal account for less than $200,000, a manageable penalty for someone who earned a few million dollars on SAC’s trading floor. And in an embarrassment for prosecutors, they charged the investment banker who they thought provided confidential information to Mr. Hollander, and then dropped the case against the investment banker entirely.

“A low-level guy sometimes doesn’t get the government where it needs to be because there is only so much information they can give,” said Allen D. Applbaum, co-leader of global risk and investigations at FTI Consulting and a former federal prosecutor. “Frequently, you can hit a dead end or a roadblock and then have to move on.”

Through his lawyer, Aitan D. Goelman, Mr. Hollander declined to comment for this article.

A native of Annapolis, Md., Mr. Hollander pursued a career on Wall Street after graduating from Tufts University and Stanford Business School. Early in his career, in the late 1990s, Mr. Hollander worked at Credit Suisse, where he became fast friends with two other ambitious young analysts — Ramesh Chakrapani and Nicos Stephanou.

The three went their separate ways but stayed in touch. Mr. Hollander eventually landed at SAC, where he spent nearly four years in its CR Intrinsic unit, a division of the fund. In November 2008, SAC, which is based in Stamford, Conn., let Mr. Hollander go during broad cuts because of the financial crisis.

Around that time, investigators learned that Mr. Stephanou, who had moved to UBS, was sharing confidential information with friends about merger deals, according to court records. That December, the F.B.I. arrested Mr. Stephanou, who began cooperating.

He told investigators about a dinner that he claimed to attend with Mr. Hollander and Mr. Chakrapani where the three freely discussed a planned buyout of the grocery business Albertsons. Mr. Stephanou and Mr. Chakrapani, who was then working as a banker at the Blackstone Group, both advised on the transaction.

F.B.I. agents approached Mr. Hollander and Mr. Chakrapani in January 2009. It was a coordinated operation. As the agents waited for Mr. Hollander to finish his workout, law enforcement officials met Mr. Chakrapani at John F. Kennedy International Airport as he walked off a plane from London.

They arrested Mr. Chakrapani and prosecutors filed a complaint charging him with tipping an unnamed hedge fund trader about the Albertsons deal. The S.E.C. filed a parallel lawsuit. Mr. Hollander was the unnamed hedge fund trader, according to lawyers close to the case. Prosecutors said that the trader — Mr. Hollander — made $3.5 million in profits for his employer by illegally trading in Albertsons stock.

Mr. Hollander, seen as a potential cooperator who could help them penetrate SAC, was not charged. After his initial meeting with agents at the Greenwich Village cafe, where Mr. Hollander appeared calm and poised, he spent two days in April being interviewed by government officials at the United States attorney’s office in Manhattan.

Prodded for information about the hedge fund giant, Mr. Hollander offered up several examples of questionable activity at SAC that he had either witnessed or had heard about, lawyers briefed on the matter said. He told the authorities about a lucrative, uncannily timed trade in the drug maker Elan, which is now at the center of Mr. Martoma’s prosecution. While investigators were already examining the transaction, Mr. Hollander reinforced their suspicions. Mr. Hollander also shared information on a more than $150 million trade at SAC involving shares of the biotechnology firm MedImmune, the lawyers said. Authorities suspected that an SAC employee placed the trade using inside information about a British company’s 2007 acquisition of MedImmune.

Some of the insights Mr. Hollander offered aided the government’s inquiry into SAC. The broader investigation has led to three onetime SAC traders pleading guilty to trading stocks based on secret corporate information while at the fund; at least seven former employees have been tied to insider trading.

Representatives for the F.B.I., the United States attorney’s office in Manhattan and the S.E.C. declined to comment.

After a flurry of activity, the cases against Mr. Chakrapani and Mr. Hollander sputtered.

In a rare reversal, just three months after bringing criminal charges against Mr. Chakrapani, prosecutors dropped them without explanation. As investigators struggled to corroborate Mr. Stephanou’s story, the S.E.C. also withdrew its lawsuit. The government said in court papers that dismissing the case against Mr. Chakrapani had nothing to do with its “assessment of Stephanou’s veracity.” Mr. Stephanou, who was detained for 19 months in jail, while cooperating, has since returned to his native Cyprus.

After Mr. Chakrapani’s arrest, Blackstone suspended him. Without a job, he moved in with his parents in California. Mr. Chakrapani recently rejoined Blackstone, according to a spokesman for the firm.

“The dismissal of the unwarranted charges brought against Mr. Chakrapani cannot undo the damage to his professional reputation,” said Michael Sommer, the lawyer who represented Mr. Chakrapani. “And it remains one of the glaring flaws in our system that the law provides little if any legal recourse for those subjected to these types of damages.”

Mr. Hollander also remained in limbo as authorities weighed his importance and the quality of the evidence against him. Some wanted to use him as a witness in a broader SAC case, according to officials briefed on the investigation, but prosecutors questioned the accuracy and utility of his tips.

Ultimately, he was never criminally charged and did not enter into a formal cooperation agreement with the government. The S.E.C. did not bring its lawsuit until 2011. And when it did, unlike the triumphal news releases that normally accompany its insider trading victories, the agency put on its Web site a brief statement about the settlement. The complaint did not mention SAC.

The S.E.C.’s case involved claims that Mr. Hollander, along with a family member and business school classmate, illegally traded Albertsons stock in their personal accounts, earning combined profits of about $96,000. Mr. Hollander agreed to pay the government $192,000, and accepted a three-year ban from the securities industry.

At the time of the settlement, Mr. Goelman, the lawyer for Mr. Hollander, said his client resolved the matter rather than engage in costly litigation.

His brush with the government seemingly over, Mr. Hollander has tried to move on. Unable to trade stocks, he started his own consulting firm, the Chesapeake Advisory Group, and also co-founded EvoSpend, a financial services technology company.

And last year, in an attempt to improve his Internet profile and de-emphasize articles about his insider trading case in Google search results, Mr. Hollander set up a series of Web pages highlighting his philanthropic pursuits and other accomplishments.

A version of this article appeared in print on 01/15/2013, on page A1 of the NewYork edition with the headline: How Pursuit of Billionaire Hit One Dead End.

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Cuban hospital carefully guards Hugo Chavez’s privacy

HAVANA (Reuters) – You would never guess that one of the world’s most famous heads of state, Venezuelan president and self-proclaimed revolutionary Hugo Chavez, is battling cancer at Havana’s Center for Medical-Surgical Research (CIMEQ).

At the weekend there was no visible increase in security at the hospital’s main entrance, where guards in olive green uniforms checked the comings and goings of visitors and waved on dallying reporters.

The sprawling, three story complex that is run by the Cuban Interior Ministry is located in leafy Siboney, one of the country’s most exclusive neighborhoods on the western edge of the Cuban capital, and just minutes from the home of Fidel Castro.

It has been a month since the once feisty and now cancer-stricken Chavez, leader of one of the world’s biggest oil producing nations, was operated on for a fourth time at the hospital. This time around, there have been no glowing reports of recovery.

CIMEQ’s best known patient, Fidel Castro, 86, has been treated there since 2006 when he was operated on for intestinal bleeding, forcing him to cede power to his brother Raul Castro.

Ironically Chavez, who often visited the man he refers to as his mentor during Castro’s ordeal, has now become CIMEQ’s second best known patient. In a dramatic reversal of fate, it is Fidel Castro who has been repeatedly at the 58-year-old Venezuelan president’s bedside, beginning with his first operation in 2011.

Hazy Venezuelan government communiques speak of unexpected bleeding during Chavez’s most recent surgery and a lung infection that has kept the 58-year-old Chavez in a “stable” but “delicate” state since mid-December.

There has not been a word, nor even a tweet from the usually vociferous Chavez. His Twitter account, with almost 4 million followers, went silent after November 1.

Meanwhile, Chavez’s family has been holding vigil in Havana, as other Venezuelan leaders and various Latin American heads of state come and go in a show of support. The presidents of Argentina and Peru visited over the weekend.

What the operation involved, and even the type of cancer attacking Chavez and its exact location, are considered state secrets.

VIP FACILITIES OFF LIMITS

CIMEQ, according to various Cuban doctors and nurses, is the Caribbean island’s finest medical facility, boasting up to date equipment and pharmaceuticals and with the authority to call in the country’s top specialists and support staff from other hospitals, as has been done in Chavez’s case.

“CIMEQ exists in the 21st century and is the equal to some of the best facilities in the world, while the rest of the country’s hospitals remain at 20th century levels,” said one local doctor who requested her name be withheld.

“There are no shortages of supplies and medicines and the food is great,” she added.

The hospital treats mainly interior ministry personnel, their families and area residents free of charge.

In a land where complaints are common, it is hard to find anyone with a bad word to say about the place, except that it is reserved exclusively for the elite.

“Unfortunately, I lost my father to cancer at CIMEQ less than a year ago,” said 47- year-old Agustín Daniel.

“He was treated for years at CIMEQ and the care was exquisite. He died because cancer kills and sometimes there is no solution,” the self-employed interior decorator said.

CIMEQ also boasts a wing for foreigners willing to pay for their care, as well as special VIP facilities for Cuba’s top leaders and important figures from other lands.

“Distinguished personalities from the arts, sciences and politics from all over the world have received attention in its modern and efficient installations,” the hospital‘s Web Page (www.cimeq.org)states.

Little is known about the hospital’s VIP accommodations, where Chavez is being treated, except that they are equipped with the latest technology and that those who work there are often sequestered for periods of time. Like all CIMEQ staff, they are sworn to secrecy at the risk of losing their licenses and criminal prosecution.

“The VIPs are treated on the third floor which is off limits to most staff even if they work for the Interior Ministry and wear uniforms under their white coats,” a doctor who has worked at CIMEQ said.

“The elevators to the third floor have guards and if the patient goes outside part of the grounds are closed off,” he said, adding, “no one knows what goes on up there.”

(Editing by David Adams and Andrew Hay)

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Not guilty pleas entered for Lohan on misdemeanors

LOS ANGELES (AP) — Lindsay Lohan pleaded not guilty Tuesday to three misdemeanor charges related to a car crash and was ordered to appear in court for a hearing later this month.

Her plea was entered by her attorney Shawn Holley, who declined to comment after the hearing. Lohan was not required to attend.

Superior Court Commissioner Jane Godfrey said the actress must appear at a Jan. 30 pretrial hearing.

Lohan is charged with lying to police, reckless driving and obstructing police from performing their duties.

Police suspect Lohan was driving her sports car when it slammed into a dump truck while she was on her way to the set of "Liz and Dick" in early June. Lohan told police she wasn't behind the wheel.

Lohan was on probation for a 2011 necklace theft case at the time and could face up to 245 days in jail if a judge determines she violated her probation.

Godfrey also set a Feb, 27 trial date on the misdemeanor counts.

The accident was not the only problem encountered by Lohan while shooting "Liz and Dick," a film based on the love affair between Elizabeth Taylor and Richard Burton.

She also was arrested in New York after an alleged fight with a woman, but a criminal complaint hasn't been drawn up. The district attorney's office there said last week that an inquiry was ongoing.

A week after the car accident, paramedics were summoned to Lohan's hotel room when she was late getting to the set. Her publicist at the time attributed her absence to fatigue and dehydration.

The film was expected to be a comeback opportunity for Lohan, who spent the past several years struggling with criminal court cases. Her performance, however, was panned by critics and fans.

___

Anthony McCartney can be reached at http://twitter.com/mccartneyAP

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Well: Turning to the Web for a Medical Diagnosis

Thirty-five percent of American adults said they have used the Internet to diagnose a medical condition for themselves or someone else, according to a new Pew Research Center study. Women are more likely than men to turn to the Internet for diagnoses. Other groups more likely to do so are younger people, white adults, people with college degrees and those who live in households with income above $75,000.

The study, released by Pew’s Internet and American Life Project on Tuesday, points out that Americans have always tried to answer their health questions at home, but that the Internet has expanded the options for research. Previous surveys have asked questions about online diagnoses, but the Pew study was the first to focus on the topic with a nationally representative sample, said Susannah Fox, an associate director at Pew Internet. Surveyors interviewed 3,014 American adults by telephone, from August to September 2012.

Of the one in three Americans who used the Internet for a diagnosis, about a third said they did not go to a doctor to get a professional medical opinion, while 41 percent said a doctor confirmed their diagnosis. Eighteen percent said a doctor did not agree with their diagnosis. As far as where people start when researching health conditions online, 77 percent said they started at a search engine like Google, Bing or Yahoo, while 13 percent said they began at a site that specializes in health information.

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DealBook: JPMorgan Board Votes to Release 'London Whale' Report

The board of JPMorgan Chase voted Tuesday to release an internal report detailing the bad bet — and related management missteps — that cost the nation’s largest bank more than $6 billion, according to several people familiar with the matter.

Since announcing the trading losses in May, JPMorgan Chase has worked to move beyond the fiasco, shuffling senior management, clawing back millions of dollars in compensation from senior executives and commissioning the internal investigation. The report, which exceeds 50 pages, is the result of the investigation, led by Mike Cavanagh, JPMorgan’s former chief financial officer.

The losses stemmed from a bungled derivatives bet made by the bank’s Chief Investment Office, which was a little-known unit with offices in London and New York. An aggressive group of traders in London built a large position that distorted the credit market and has prompted $6.2 billion in losses.

Some within the bank were wary of releasing the report, which takes aim at lax supervision and risk controls, according to the people who insisted on anonymity because the discussions were not public. One concern was that plaintiff lawyers might seize on the report, the people said.

But Jamie Dimon, the bank’s chief executive, argued that the report should be released. The report is expected to be critical of Douglas Braunstein, formerly the bank’s chief financial officer, for failing to strictly monitor the activities of the traders in London.

Ahead of JPMorgan’s earnings announcement on Wednesday, the board met to discuss whether to make the report public. Also on the agenda is whether to reduce the bonuses of Mr. Dimon and Mr. Braunstein. Mr. Dimon, these people said, could have his annual payout cut by as much as 20 percent.

Among the six largest banks in the United States, Mr. Dimon was the highest-paid chief executive, taking home $23.1 million in 2011. That year, his total pay package was made up of stock and option awards along with a $4.5 million cash bonus.

A spokesman for JPMorgan Chase did not immediately return calls for comment.

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Ex-President George H.W. Bush Leaves the Hospital

HOUSTON (AP) — Former President George H.W. Bush was released from a Houston hospital Monday after spending nearly two months being treated for a bronchitis-related cough and other health issues, a family spokesman said.

Bush, 88, the nation's oldest living former president, was admitted to Methodist Hospital Nov. 23 including a week in intensive care last month.

"I am deeply grateful for the wonderful doctors and nurses at Methodist who took such good care of me," Bush said in a statement released by spokesman Jim McGrath. "Let me add just how touched we were by the many get-well messages we received from our friends and fellow Americans. Your prayers and good wishes helped more than you know, and as I head home my only concern is that I will not be able to thank each of you for your kind words."

Bush already had been in the hospital about a month for treatment of the persistent cough in December when his office disclosed he was in intensive care because physicians were having difficulty controlling a fever that developed after the cough was mostly resolved.

On Dec. 29, Bush's office said the former president had improved and was transferred back to a regular hospital room. Since then, his condition has continued to improve and he has been undergoing physical therapy to rebuild his strength.

"Mr. Bush has improved to the point that he will not need any special medication when he goes home, but he will continue physical therapy," Dr. Amy Mynderse, the internal medicine physician in charge of the former president's care, said in Monday's statement.

Bush and his wife, Barbara, live in Houston during the winter and spend their summers at a home in Kennebunkport, Maine. On Jan. 6, they celebrated their 68th wedding anniversary. They are the longest-married presidential couple.

Bush had served two terms as Ronald Reagan's vice president when he was elected in 1988 to be the nation's 41st president. Four years later, after a term highlighted by the success of the 1991 Gulf War in Kuwait, he lost to Democrat Bill Clinton.

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Coroner releases new report on Natalie Wood death

LOS ANGELES (AP) — A newly released report shows coroner's officials amended Natalie Wood's death certificate based on unanswered questions about bruises on her upper body but were lacking several pieces of evidence and could only conclude that she drowned under undetermined circumstances more than 30 years ago.

Los Angeles County coroner's officials state in an 10-page addendum to Wood's autopsy report that some of the bruises may have occurred before she went into the water and drowned, but that could not be definitively determined.

The report reveals new details about a renewed investigative interest in Wood's case, but it does not answer many of lingering questions about the actress' death and a Sheriff's Department spokesman said it has not changed the ongoing status of the case.

Officials reviewed Wood's case after sheriff's investigators in late 2011 renewed their inquiry into her November 1981 drowning. Wood's death certificate was amended last year to change her cause of death from drowning to "drowning and other undetermined factors" and the report released Monday details the reasons for the alteration.

The certificate was also amended to state that the circumstances of how the Oscar-nominated actress ended up in the water were "not clearly established."

Wood was on a yacht off Catalina Island with husband Robert Wagner and co-star Christopher Walken on Thanksgiving weekend in 1981 before somehow ending up in the water. A dinghy that was attached to the boat was found along the island's shoreline, but investigators could not locate it to review it last year.

Several of the original coroner's investigators who worked on the case were re-interviewed, and officials attempted to test some items taken during the investigation into Wood's death and an autopsy, but they could not be located.

Wood's autopsy found bruises on both of her arms, a small scratch on her neck and abrasions described as superficial on her forehead, left brow and cheek.

"The location of the bruises, the multiplicity of the bruises, lack of head trauma, or facial bruising support bruising having occurred prior to entry in the water," the report states. "Since there are unanswered questions and limited additional evidence available for evaluation, it is opined by this Medical Examiner that the manner of death should be left as undetermined," Chief Medical Examiner Dr. Lakshmanan Sathyavagiswaran wrote in the report completed in June.

Officials also considered that Wood wasn't wearing a life jacket and had no history of suicide and didn't leave a note in amending its report and Wood's death certificate.

The report was released Monday after sheriff's officials released a security hold.

Sheriff's spokesman Steve Whitmore said the agency has known about the findings in the newly released autopsy report for several months and it does not change the status of the investigation, which remains open. He said Wagner is not considered a suspect in Wood's death.

Wood was nominated for three Academy Awards during her lifetime. Her death stunned the world and has remained one of Hollywood's most enduring mysteries. The original detective on the case, Wagner, Walken have all said they considered her death an accident.

Conflicting versions of what happened on the yacht shared by Wood, her actor-husband Robert Wagner and their friend, actor Christopher Walken, have contributed to the mystery of how the actress died.

The newly released report states there are conflicting statements about when the boat's occupants discovered Wood was missing. The report estimates her time of death was around midnight, and she was reported missing at 1:30 a.m.

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The New Old Age Blog: What You Need to Bring Your Loved One Home to Die

Most of us, when asked about how and where we want to die, answer simply “at home.” Making that happen is not always as simple as it sounds. After a post in November, “Turning a Home into a Hospital,” some readers of this blog left comments asking what equipment they needed on hand and what other steps they needed to take to make that last wish a reality.

To even begin to answer that, you have to consider two things – not simply the patient’s situation, but the caregiver’s, too, said Dr. R. Sean Morrison, director of the National Palliative Care Research Center at the Mount Sinai School of Medicine in New York.

“What I see that prevents people from being able to stay at home [to die] is not their medical needs but the needs of their caregiver — can the caregiver really help, are there resources to help, or is that person going to be overwhelmed?” Dr. Morrison said.

There is professional help available. But before we get to that, here are what specialists say are the most common kinds of equipment and preparations you may need – though, of course, every person’s medical and emotional condition is different, as is every person’s home.

1. Make room for the bed.
One of the trickiest parts of bringing the patient home is realizing that the bedroom may not be the best place to put the bed, especially if it’s located up even a few stairs. “A lot of people put the patient in a family room where there is more space, or the dining room if it’s closer to a bathroom,” said Dr. Stacie K. Levine, a geriatrician and palliative care physician at the University of Chicago. Or you might consider a room closer to the kitchen – the center of life and activity for most families.

2. Don’t forget curtains for privacy.
You can still provide privacy for whichever room you decide to turn into the bedroom by putting up a temporary curtain using a spring pressure curtain rod in the doorway. Especially in the patient’s already vulnerable state, a little privacy can go a long way toward preserving dignity.

3. Get tools that keep them moving.
Walkers, four-point canes and slim wheelchairs all help the patient to get out of bed and take part in daily life (and are covered by Medicare). To get the house ready for this new equipment, Dr. Levine cautioned, you will have to remove slippery throw rugs, as well as chairs and other furniture that can get in the way. (See this earlier post and this post for more details on reducing fall hazards at home.)

Changing door handles from knobs to levers can make moving from room to room easier on the patient feeling weak or suffering from painful arthritis.

4. Fix their favorite chairs.
Many patients find that they are just too weak to get up from what used to be their favorite chair. You can buy risers or foam cushions to put on the seats — or replace a side chair with an armchair — to give them extra leverage and allow them to stay in their old spots comfortably.

5. Experiment with earphones.
You may need several models to fit into the TV, radio and iPods or tape players so those who are losing their hearing can still enjoy their entertainment, whenever they choose, without disturbing the rest of the household.

6. Make the existing bathroom safer.
“You’ll need to install grab bars or benches inside the tub,” Dr. Levine said. (Note: Tub benches, costing about $30 to $40, are one of the few things Medicare does not cover, according to Janet Wulf, a home care registered nurse with Gilchrist Hospice Care in Baltimore, the largest hospice organization in Maryland. Convertible commodes with arms that fit over the existing toilet – and solid foam risers that fit on the toilet seat — make sitting and getting up easier.

“Sometimes we suggest changing the shower head to install a hand-held shower head so that they can still participate in bathing themselves,” Dr. Levine advised. Putting down nonskid bathmats with a rubber underside also helps prevent slipping. (Find other bathroom and household safety tips in an earlier post on fall prevention.)

7. Good lighting is critical.
Nighttime trips to the bathroom or even moving down poorly lit corridors on an overcast day can pose serious falling hazards for those whose eyes and minds may be declining. Night lights with light sensors in every room and hallway of the house are an energy-and-cost-efficient way to keep pathways lit and safe.

8. Bedside commodes are a delicate matter.
People resist bedside commodes, said Dr. Morrison. It’s not only the lack of privacy, but it makes them feel like invalids. Dr. Morrison said he stresses with patients that it’s safer than slipping and falling on the way to the bathroom. And it can be done discreetly. “I say, ‘We can put it there at night and move it in the morning.’”

What if they still balk, as many do? Dr. Morrison had this useful reminder: “Our parents are adults and they are allowed to make bad decisions.”

9. Make breathing easier.
If the patient experiences breathlessness, common for those with heart and lung disease, Dr. Morrison said, oxygen equipment can ease the discomfort and the anxiety that gasping for breath can trigger. The caregiver needs to practice not only operating the machines, but getting the long, plastic oxygen tubing out of the way as the patient moves around the house.

10. Are pain pumps or intravenous drips for pain helpful?
In most cases, they are not necessary. “We can control pain orally with medication that comes in highly concentrated form, so even if patients can’t swallow, they can have pain control,” Dr. Levine said. Or the patient can get a steady baseline of pain medication by wearing a skin patch, or a nurse can administer a shot (through the skin, not the muscle, which would itself be painful).

Occasionally, for those with long-standing pain issues who require unusually high doses of medication, an intravenous drip can deliver a steady supply, which can be controlled by the patient with a button (within limits) or by a nurse or caregiver.

In even more rare cases, for patients with the highest pain-control needs, an intrathecal pain pump can be inserted into the intrathecal space around the spine area, “much like an epidural used in childbirth,” Dr. Levine said, and added that “It is an invasive procedure and requires a lot of monitoring.” So it is most commonly used as a solution for chronic pain over many years – and rarely recommended for those with less than a few months to live.

11. Should you order a hospital bed?
The idea of bringing this piece of equipment home sparks some of the most emotional disputes, among patients and caregivers alike.

“It’s a big deal to give up sleeping with a lifetime partner and the warmth and comfort of sleeping together,” Ms. Wulf said.

It is also the one piece of equipment that clearly turns the home into a hospital. Small wonder so many resist, as the blogger who wrote the “Turning Home into a Hospital” post admitted.

“And there is the issue of where are you going to put it?” said Ms. Wulf, as the hospital bed is not only an extra bed in the home, but it is slightly longer than a regular twin bed.

But if your loved one is having trouble getting in and out of a regular bed, and your back is being strained as you help, the hospital bed, which lowers, can make that process safer and easier for both of you. (It is covered by Medicare.) Similarly, being able to raise the hospital bed can make assisting with dressing, changing adult diapers and making up the bed a lot easier.

Also, because the head and foot of the hospital bed can be adjusted separately, it can make patients (especially those with heart and lung disease who need propping up to prevent fluid from accumulating in the lungs and legs) more comfortable than they would be lying flat or propped up with an assortment of pillows.

For those with dementia, who forget to change position, or with cancer and other ailments that leave them too weak to move around, the hospital bed — with an air compression mattress — will do the job for them. It can prevent bedsores, which, according to Dr. Levine, “can start very soon in somebody who isn’t turned and repositioned every three hours” all day and night.

12. Consider hospice.
Equipment aside, one of the biggest resources that a caregiver can call upon in these last stages, in addition to backup care from family, friends and home health aides, is hospice — as we’ve talked about in this blog many times. I can tell you from my family’s recent experience that hospice is like sending in a team of loving aunts – only they’re far more patient (no family baggage) and way more competent.

A good hospice team not only helps the caregiver figure out a plan for care but arranges for Medicare approval and payment. What many don’t know is that hospice even covers “respite care” for the caregiver – paying for up to five days of room and board for the patient in a nearby medical facility (or nursing home) so the caregiver can take a break – even to go on vacation, according to Lori Mulligan, senior director of development marketing and community services at Gilchrist Hospice Care, the largest hospice care organization in Maryland.

But as this blog has written many times before, too many people wait until the very end to call hospice. The median time in hospice is about 19 days, and more than a third of patients wait until the last week, according to the 2012 report tracking hospices nationwide from the National Hospice and Palliative Care Organization.

Why don’t they take advantage of the six months of extra help at home that they are eligible for under Medicare once a prognosis is made?

First, “clinicians are not great at prognosis” until the very end, said Dr. Levine. And the patient and family aren’t always ready to hear it.

“When people think of hospice, they think, ‘Oh, my mom will be lying in bed all the time,’” Dr. Levine said. Or they worry that calling in hospice may actually hasten death. Instead, Dr. Levine has found just the opposite.

“I have been doing this for over a decade and I find my patients who choose hospice sooner at home may live a little longer,” said Dr. Levine. When you shift the focus from a full-court press on cure (hospitals’ goals) to providing comfort (hospice credo), patients can stop using all their energy to fight the pain, so they are more likely to have the energy to “eat and walk and do all the things they like to do that keep us alive,” Dr. Levine added.

How do you know when it’s time?

Dr. Levine advises: Ask yourself if you would be surprised if the person you’re caring for would die within six months. And ask the patient about his or her goals. If he or she feels that all the treatment options have been exhausted but the disease is still progressing, and the patient is tired, doesn’t want to go back into the hospital, and just wants the comfort of their own bed — then it may be time to go home.

One more thing to bear in mind if you decide to call hospice: size matters.

“The larger the hospice, usually the more services for the patient and caregiver,” said Dr. Morrison, referring to a 2011 study in Medical Care journal supporting the bigger-is-better rule of thumb. “Ask for their daily patient census – several hundred patients per day is a good size,” Dr. Morrison added.

Remember, the point of all this is to make both the patient and the caregiver as comfortable as possible in those final days.

For most of us that can mean, “There’s no place like home.”

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F.D.A. Warns St. Jude Medical

St. Jude Medical, a maker of medical devices, said Monday that it had received a warning letter from federal regulators concerning manufacturing issues at its Sylmar, Calif., plant, where it makes cardiac rhythm management products.

In a regulatory filing, St. Jude said the Food and Drug Administration had noted in the letter that it would not approve certain new product applications until the quality system violations were corrected.

The letter does not identify any specific concerns about the performance of the company’s Riata ST Optim or Durata leads or any other St. Jude Medical product, the company said.

St. Jude said it would continue manufacturing and shipping products from the Sylmar plant, and that customer orders were not expected to be affected while it works to resolve the F.D.A.'s concerns.

In October, the company disclosed that it might receive such a letter from the F.D.A.

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Sonia Sotomayor Makes Herself at Home in Washington

Todd Heisler/The New York Times

Justice Sonia Sotomayor visiting the Bronx housing project where she grew up.

WASHINGTON — Justice Sonia Sotomayor is a proud daughter of New York City, and her adjustment to life in the nation’s capital has been rocky. Do not get her started, for instance, about ordering takeout.

“I go to New York, I order food, it’s at my door in 10 to 15 minutes. O.K.?” she said in an interview in her Supreme Court chambers. In Washington, she said, “there isn’t a place I call where it doesn’t take 45 minutes.”

“And then getting the food delivered to the Supreme Court? They’ve got to stop at security, security has to call you, you’ve got to go downstairs. By the time you get downstairs you may add another 15 minutes to the 45 minutes. And the food is ice-cold.”

There are four justices from New York City these days, each representing a different borough, and it sometimes seems that the court speaks with a New York accent.

Justice Sotomayor, who grew up in the Bronx, recalled getting to know Justice Antonin Scalia, who is from Queens and whose friends call him Nino.

“One day Nino looked at me and said: ‘You’re a real New Yorker. I love you. You take as well you give,’ ” she said with a big laugh. “And I understood. You know, we’re just out there and up front and fun.”

She mentioned a second colleague, Justice Elena Kagan. "I dare say Elena has a little bit of that." Justice Kagan is from Manhattan, and ustice Ruth Bader Ginsburg, who is more reserved, is from Brooklyn.

“The boroughs are different,” Justice Sotomayor said, “and so are we.”

The occasion for the chat was the publication of her memoir, “My Beloved World.” It is steeped in vivid memories of New York City, and it is an exceptionally frank account of the challenges that Justice Sotomayor faced during her ascent from a public housing project to the court’s marble palace on First Street.

Justice Sotomayor turns out to be a writer of depth and literary flair, a surprise to readers of her judicial prose. (“I am a lawyer’s judge,” she said on hearing the observation. “I write very technically.”)

Her chambers are sleek, modern, filled with light and bursting with pottery, art and mementos. There are photographs of her relatives, a group portrait of the four women ever to serve on the Supreme Court and one of Justice Sotomayor with President Obama, who appointed her in 2009.

In a corner, there is a bag overflowing with characters from “Sesame Street,” where she has been known to dispense advice. (“Pretending to be a princess is fun, but it is definitely not a career,” she said in an appearance on the show in November, offering alternatives: “You can go to school and train to be a teacher, a lawyer, a doctor, an engineer and even a scientist.”)

And there is a sign of the sort you might find in the novelty section of a gift shop: “Well-behaved women rarely make history.”

Justice Sotomayor’s book ends in 1992 with her appointment to Federal District Court in Manhattan. There are only stray references in the memoir to her service there, on the United States Court of Appeals in New York, where she served from 1998 to 2009, and on the Supreme Court.

But her life story, which includes chapters at Princeton, Yale Law School, the Manhattan district attorney’s office and private practice as a civil litigator, illuminates her judicial work.

She acknowledged that she entered the Ivy League through “a special door” and that her adjustment was rough. “I felt like an alien landing in a different universe,” she said of her arrival at Princeton.

Her childhood was so urban that she confused cows and horses. “I didn’t know what a cricket sounded like,” she said.

She was part of vanguard not always welcomed by the old order. In the book, she recalled letters in The Daily Princetonian “lamenting the presence on campus of ‘affirmative action students,’ each of whom had presumably displaced a far more deserving affluent white male and could rightly be expected to crash into the gutter built of her own unrealistic aspirations.”

“There were vultures circling, ready to dive when we stumbled,” she wrote.

She did not stumble. On graduating, she was awarded the Pyne Prize, the university’s highest undergraduate award, presented for a combination of academic success and extracurricular work.

Asked if the programs from which she benefited are still needed, she was initially vague, perhaps as a consequence of a pending case about the constitutionality of the University of Texas’s affirmative action plan.

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